Histologic acute graft pyelonephritis after kidney transplantation: Incidence, clinical characteristics, risk factors, and association with graft loss.

BACKGROUND: Histologic acute graft pyelonephritis (HAGPN) after kidney transplantation (KT) has been assessed less frequently than urinary tract infections (UTIs) or clinical acute graft pyelonephritis. Risk factors for HAGPN, its association with graft loss, and measures that might prevent it are not known. METHODS: We performed a retrospective review of HAGPN cases identified from KT occurring between January 2008 and December 2017 at our institution. We compared the HAGPN cases to a randomly selected control group of KTs to identify risk factors using univariate and multivariate Cox regression models. The association between HAGPN and graft loss was also assessed, similarly. RESULTS: HAGPN was identified in 46 of 1391 patients (cumulative incidence, 5% [95% CI, 3%-7%]) undergoing KT at a single center from January 2008 through December 2017 (median time to diagnosis, 241 days after KT; interquartile range, 122-755 days). Indications for biopsy were follow-up of treated rejection (n = 20 [43%]), KT protocol biopsy (n = 19 [41%]), and acute kidney injury (n = 7 [15%]). Histologic rejection, UTI, and asymptomatic bacteriuria (ASB) were present in 23 (50%), 9 (20%), and 16 (35%). Multivariate Cox proportional hazards models comparing KT recipients with or without HAGPN (n = 46 and n = 138, respectively) showed that HAGPN was associated with urologic complication by day 30, delayed graft function, previous UTI or ASB, and a history of rejection. In the univariate and multivariate analyses, HAGPN was associated with an increased risk of graft loss. CONCLUSION: HAGPN is an infrequent, unanticipated, and clinically significant complication of KT.

Improving Value of Care: Cessation of Screening Urine Culture Prior to Orthopedic and Spinal Surgery.

OBJECTIVE: To assess the impact of cessation of screening urine cultures on surgical site infection (SSI) incidence in clinical practice. PATIENTS AND METHODS: Our study included patients undergoing hip replacement, knee replacement, spinal fusion, and laminectomy 12 months before (preintervention) and after (postintervention) cessation of preoperative screening urine cultures on June 1, 2017, at our institution. Urine cultures and urinalyses performed within 30 days before surgery during the 12 months before and after cessation were reviewed. SSI surveillance was performed in accordance with the methods of the National Healthcare Safety Network. RESULTS: A total of 2754 patients were included (1286 preintervention and 1468 postintervention). In the preintervention period, 1141 urine cultures were performed, compared to 153 in the postintervention period; 35 and 6 episodes of asymptomatic bacteriuria were treated, respectively. The occurrence of SSI did not differ noticeably between time periods (1.2% vs 0.7%, P=.24), and quarterly incidences of SSI were unchanged. The rate of SSI was significantly lower in the postintervention period for laminectomy (3.0% vs 0.3%, P=.02). CONCLUSION: An 86.6% (153 vs 1141) reduction in screening urine cultures over a 12-month period was associated with a reduction of 988 unnecessary urine cultures, an 82.8% (6 vs 35) decline in inappropriate antibiotic treatment of asymptomatic bacteriuria, and no increase in SSI incidence after hip replacement, knee replacement, spinal fusion, or laminectomy procedures. No value of screening urine cultures before clean surgery was identified.

The validity of validation: A practical assessment.

OBJECTIVE: To assess the time to achieve reliable reporting of electronic health record data compared with manual reporting during validation. DESIGN: Secondary analysis of aggregate data for number of patients present, number of patients with a central venous catheter, and number of patients with an indwelling urinary catheter during validation of an electronic health record reporting tool. SETTING: Mayo Clinic Health System in Wisconsin. PARTICIPANTS: Mayo Clinic infection prevention and control staff, unit champions, and all inpatients. METHODS: We simultaneously collected electronic and manual counts of device data and compared discrepancies to determine their source. If manual data entry was incorrect, manual counts were coded as inaccurate. If electronically abstracted data did not reflect an accurate count, errors were attributed to the system. Data were compared using standard statistical methods. RESULTS: Within 30 days after beginning validation of electronic reporting for central venous catheter days and urinary catheter days, electronic counts were durably more reliable than manual counts. CONCLUSIONS: Manual validation for capturing and reporting electronic data and reporting can be shorter than the 90 days currently mandated by National Healthcare Safety Network criteria. Compared with a longer validation period, a shorter validation period may yield substantial savings while achieving the same validity.

Long-term follow-up of post-cardiac surgery Mycobacterium chimaera infections: A 5-center case series.

OBJECTIVES: In multiple countries, endovascular/disseminated Mycobacterium chimaera infections have occurred in post-cardiac surgery patients in association with contaminated, widely-distributed cardiac bypass heater-cooler devices. To contribute to long-term characterization of this recently recognized infection, we describe the clinical course of 28 patients with 3-7 years of follow-up for survivors. METHODS: Identified at five hospitals in the United States 2010-2016, post-cardiac surgery patients in the cohort had growth of Mycobacterium avium complex (MAC)/M. chimaera from a sterile site or surgical wound, or a clinically compatible febrile illness with granulomatous inflammation on biopsy. Case follow-up was conducted in May 2019. RESULTS: Of 28 patients, infection appeared to be localized to the sternum in four patients. Among 18 with endovascular/disseminated infection who received combination anti-mycobacterial treatment and had sufficient follow-up, 39% appeared to have controlled infection (>12 months), 56% died, and one patient is alive with relapsed bacteremia. While the number of patients is small and interpretation is limited, four (67%) of six patients who had cardiac prosthesis removal/replacement appeared to have controlled infection compared to three (25%) of 12 with retained cardiac prosthesis (p >0.14; Fisher's exact test). CONCLUSIONS: Given poor response to treatment and potential for delayed relapses, post-cardiac surgery M. chimaera infection warrants aggressive treatment and long-term monitoring.

Adenovirus pseudo-outbreak associated with bronchoscopy.

Introduction and regular application of multiplex polymerase chain reaction analysis of bronchoalveolar specimens for community-acquired respiratory viruses in January 2017 led to the identification of adenovirus in multiple patients in a surgical intensive unit in July 2017, which was attributed to a pseudo-outbreak.

The cost of a recalcitrant intravenous drug user with serial cases of endocarditis: Need for guidelines to improve the continuum of care.

We report a case of an intravenous drug user (IVDU) patient who had 4 episodes of endocarditis within a 2-year time period in rural Georgia. The institutional cost was approximately $380,000. The lack of an established transitional care plan for IVDUs to outpatient care is a common phenomenon at institutions. Guidelines are essential to optimize the quality of care rendered to IVDUs with such infections, to assist providers in utilizing limited resources, and to limit the cost to the institutions.

Assessment of an automated surveillance system for detection of initial ventilator-associated events.

Surveillance for initial ventilator-associated events (VAEs) was automated and compared with nonautomated review of episodes of mechanical ventilation. Sensitivity, specificity, positive predictive value, and negative predictive value of automated surveillance were very high (>93%), and automated surveillance reduced the time spent on detection of VAEs by >90%.

Surgical site infections after liver retransplantation: incidence and risk factors.

Surgical site infections (SSIs) after liver transplantation (LT) are associated with an increased risk of graft loss and death. The incidence of SSIs after LT and their risk factors have been determined for first LT but not for second LT. The importance of reporting the incidence of SSIs risk-stratified by first LT versus second LT is not known. All patients undergoing second LT at a single institution between 2003 and 2011 (n = 152) were reviewed. The Kaplan-Meier method was used to estimate the cumulative SSI incidence. Relative risks (RRs) and 95% confidence intervals (CIs) from Cox proportional hazards regression models were used to evaluate associations of potential risk factors with SSIs after second LT. Thirty-one patients developed SSIs (6 superficial SSIs, 1 deep SSI, and 24 organ/space SSIs). The cumulative incidence of SSIs 30 days after LT was 20.8% (95% CI = 14%-27%), which was slightly but not significantly higher than the previously reported incidence of SSIs after first LT at our institution between 2003 and 2008 (16%, RR = 1.32, 95% CI = 0.90-1.93, P = .16). Units of transfused red blood cells [RR (doubling) = 1.38, 95% CI = 1.02-1.86, P = .04] and hepaticojejunostomy (RR = 2.22, 95% CI = 1.05-4.72, P = .04) were the only factors associated with SSIs after second LT in single-variable analysis. The associations weakened in a multivariate analysis (P = .07 and P = .07, respectively), potentially because of the correlation of red blood cell transfusions and hepaticojejunostomy (P = .08). In conclusion, the incidence of SSIs after second LT was slightly higher but not significantly different than the published incidence of SSIs (16%) after first LT at the same institution. Significant independent risk factors for SSIs after second LT were not identified. Risk stratification for retransplantation may not be necessary when the incidence of SSIs after LT is being reported.

Intravascular catheter-related bloodstream infection.

Intravascular catheters required for the care of many hospitalized patients can give rise to bloodstream infection, a complication of care that has occurred most frequently in intensive care unit (ICU) settings. Elucidation of the pathogenesis of catheter-related bloodstream infections (CRBSIs) has guided development of effective diagnostic, management, and prevention strategies. When CRBSIs occur in the ICU, physicians must be prepared to recognize and treat them. Prevention of these infections requires careful attention to optimal catheter selection, insertion and maintenance, and to removal of catheters when they are no longer needed. This review provides a succinct summary of the epidemiology, pathogenesis, and microbiology of CRBSIs and a review of current guidance for the diagnosis, management, and prevention of these infections.

Health care-associated hepatitis C virus infections attributed to narcotic diversion.

BACKGROUND: Three cases of genetically related hepatitis C virus (HCV) infection that were unattributable to infection control breaches were identified at a health care facility. OBJECTIVE: To investigate HCV transmission from an HCV-infected health care worker to patients through drug diversion. DESIGN: Cluster and look-back investigations. SETTING: Acute care hospital and affiliated multispecialty clinic. PATIENTS: Inpatients and outpatients during the period of HCV transmission. MEASUREMENTS: Employee work and narcotic dispensing records, blood testing for HCV antibody and RNA, and sequencing of the NS5B gene and the hypervariable region 1 of the E2 gene. RESULTS: 21 employees were recorded as being at work or as retrieving a narcotic from an automated dispensing cabinet in an area where a narcotic was administered to each of the 3 case patients; all employees provided blood samples for HCV testing. One employee was infected with HCV that had more than 95% NS5B sequence homology with the HCV strains of the 3 case patients. Quasi-species analysis showed close genetic relatedness with variants from each of the case patients and more than 97.9% nucleotide identity. The employee acknowledged parenteral opiate diversion. An investigation identified 6132 patients at risk for exposure to HCV because of the drug diversion. Of the 3929 living patients, 3444 (87.7%) were screened for infection. Two additional cases of genetically related HCV infection attributable to the employee were identified. LIMITATION: Of the living patients at risk for HCV exposure, 12.3% were not tested. CONCLUSION: Five cases of HCV infection occurring over 3 to 4 years were attributed to drug diversion by an HCV-infected health care worker. Studies of drug diversion and assessments of strategies to prevent narcotics tampering in all health care settings are needed. PRIMARY FUNDING SOURCE: None.

Association of cytomegalovirus infection and disease with recurrent hepatitis C after liver transplantation.

BACKGROUND: Cytomegalovirus (CMV) has been inconsistently associated with recurrent hepatitis C virus (HCV) after liver transplant (LT). METHODS: A retrospective study of 347, donor or recipient CMV seropositive, first LT recipients transplanted for HCV was performed to evaluate the associations of CMV infection and disease occurring within 1-year of LT with the primary endpoints of allograft inflammation grade ≥2 and fibrosis stage ≥2. Associations were evaluated using multivariable Cox regression models. RESULTS: CMV infection and disease occurred in 111 (32%) and 24 (7%) patients, respectively. Hepatic allograft inflammation grade ≥2 and fibrosis stage ≥2 occurred in 221 (64%) and 140 (40%) patients, respectively. CMV infection was associated with increased risk of fibrosis stage ≥2 (relative risk [RR], 1.52; P=0.033). CMV disease was associated with increased risk of inflammation grade ≥2 (RR, 3.40; P<0.001), and although not significant, with fibrosis stage ≥2 (RR, 2.03; P=0.052). These associations did not differ significantly according to recipient CMV seropositivity. CONCLUSIONS: Our results support an association between CMV infection and disease with recurrence of HCV after LT. Investigation of prevention of CMV infection and disease as a strategy to mitigate recurrent HCV in LT recipients is warranted.

Glucose meters and opportunities for in-hospital transmission of infection: Quantitative assessment and management with and without patient assignment.

BACKGROUND: Increasing use of glucose meters in hospitals has increased opportunities for infection transmission that have not been quantitatively assessed or managed. METHODS: Before-and-after study of the effects of augmentation of glucose meter inventory and of assignment of glucose meters to individual patients on the sequential use of glucose meters on different patients in a 214-bed hospital. RESULTS: During October 2008, 11,665 measurements were performed using 38 glucose meters on 803 patients. A total of 9,302 tests (79.7%) was performed sequentially within 24 hours on different patients. From October 28 through November 27, 2009, the glucose meter inventory on 3 high-use units glucose meters was increased (from 22 to 87) with meters assigned to individual patients; on 4 low-use units, glucose meter inventory was increased (from 16 to 28) without assignment to individual patients. Sequential glucose meter use on different patients within 24 hours decreased by 95.1% on high-use units and increased by 17% on low-use units. CONCLUSION: Use of glucose meters was associated with a high number of opportunities to transmit infections, and those opportunities were reduced only when glucose meters were assigned to individual patients. Recent guidance from the Centers for Disease Control and Prevention and the US Food and Drug Administration to assign glucose meters to individual persons whenever possible is relevant to inpatient care.

Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors.

OBJECTIVE: The objective of this study is to determine the optimal timing for surgical antimicrobial prophylaxis (AMP). SUMMARY BACKGROUND DATA: National AMP guidelines should be supported by evidence from large contemporary data sets. METHODS: Twenty-nine hospitals prospectively obtained information on AMP from 4472 randomly selected cardiac, hip/knee arthroplasty, and hysterectomy cases. Surgical site infections (SSIs) were ascertained through routine surveillance, using National Nosocomial Infections Surveillance system methodology. The association between the prophylaxis timing and the occurrence of SSI was assessed using conditional logistic regression (conditioning on hospital). RESULTS: One-hundred thirteen SSI were detected in 109 patients. SSI risk increased incrementally as the interval of time between antibiotic infusion and the incision increased (overall association between timing and infection risk P = 0.04). When antibiotics requiring long infusion times (vancomycin and fluoroquinolones) were excluded, the infection risk following administration of antibiotic within 30 minutes prior to incision was 1.6% compared with 2.4% associated with administration of antibiotic between 31 to 60 minutes prior to surgery (OR: 1.74; 95% confidence interval, 0.98-3.04). The infection risk increased as the time interval between preoperative antibiotic and incision increased or if the antibiotic was first infused after incision. Intraoperative redosing (performed in only 21% of long operations) appeared to reduce SSI risk in operations lasting more than 4 hours (OR of 3.08 with no redosing; 95% confidence interval 0.74-12.90), but only when the preoperative dose was given correctly. CONCLUSIONS: These data from a large multicenter collaborative study confirm and extend previous observations and show a consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision.

Surgical site infection after liver transplantation: risk factors and association with graft loss or death.

BACKGROUND: Risk factors for surgical site infection (SSI) after liver transplantation and outcomes associated with these infections have not been assessed using consensus surveillance and optimal analytic methods. METHODS: A cohort study was performed of patients undergoing first liver transplantation at Mayo Clinic, Jacksonville, Florida, in 2003 and 2004. SSIs were identified by definitions and methods of the National Nosocomial Infections Surveillance System. Measures of known or suspected risk factors for SSI, graft loss, or death were collected on all patients. Associations of SSI with these factors and also with the primary composite endpoint of graft loss or death within 1 year of liver transplantation were examined using Cox proportional hazards models; relative risks (RRs) were estimated along with 95% confidence intervals (CIs). RESULTS: Of 370 patients, 66 (18%) had SSI and 57 (15%) died or sustained graft loss within 1 year after liver transplantation. Donor liver mass-to-recipient body mass ratio of less than 0.01 (RR 2.56; 95% CI 1.17-5.62; P=0.019) and increased operative time (RR 1.19 [1-hr increase]; 95% CI 1.03-1.37; P=0.018) were associated with increased SSI risk. SSI was associated with increased risk of death or graft loss within the first year after liver transplantation (RR 3.06; 95% CI 1.66-5.64; P<0.001). CONCLUSION: SSI is associated with increased risk of death or graft loss during the first year after liver transplantation. Increased operative time and decreased donor liver-to-recipient body mass ratio showed evidence of association with SSI.

Effect of antiviral chemoprophylaxis on adverse clinical outcomes associated with cytomegalovirus after liver transplantation.

OBJECTIVE: To assess t he association be tweencytomegalovirus (CMV) serology of donor and recipient and adverse outcomes afterliver transplantation in the era of effective antiviral chemoprophylaxis. PATIENTS AND METHODS: We performed a retrospective cohort study of 193 consecutive patients undergoing their first liver transplantation between February 1998 and July 2000 with targeted and preemptive ganciclovir chemoprophylaxis. Patients were divided into 4 groups by CMV serology of donor and recipient: donor-/recipient-; donor-/recipient+; donor+/recipient+; and donor+/recipient-. Survival to the end points of retransplantation, death, or survival to 1 year after transplantation (whichever occurred first) was assessed. Rates of bacterial, fungal, and CMV Infection and of CMV disease were recorded and compared. RESULTS: No significant differences were observed in the rates of retransplantation, death, or survival to 1 year among the 4 groups of patients. Despite significantly higher rates of CMV infection in the donor+ groups, there were no differences in the rates of bacterial or fungal Infection or of CMV disease. Rejection occurred least frequently in the donor-/recipient- group. CONCLUSION: The adverse effects of CMV on outcomes after liver transplantation have been diminished in the era of effective antiviral chemoprophylaxis.

Peritonitis after liver transplantation: Incidence, risk factors, microbiology profiles, and outcome.

Peritonitis occurring after liver transplantation (PLT) has been poorly characterized to date. The aims of this study were to define the incidence, risk factors, microbiology profiles, and outcome of nonlocalized PLT. This was a retrospective study of 950 cadaveric liver transplantation (LT) procedures in 837 patients, followed for a mean of 1,086 days (range, 104-2,483 days) after LT. PLT was defined as the presence of at least one positive ascitic fluid culture after LT. There were 108 PLT episodes in 91 patients occurring at a median of 14 days (range, 1-102 days) after LT. Significant risk factors associated with the development of PLT by multivariate analysis included pre-LT model for end-stage liver disease score, duration of LT surgery, Roux-en-Y biliary anastomosis, and renal replacement therapy after LT. Biliary complications, intra-abdominal bleeding, and bowel leak/perforation were associated with 34.3%, 26.9%, and 18.5% of episodes, respectively. Multiple organisms, gram-positive cocci, fungus, and multidrug-resistant bacteria were isolated in 61.1%, 92.6%, 25.9%, and 76.9% of ascitic fluid cultures, respectively. The 28 fungal PLT episodes were associated with bowel leak/perforation and polymicrobial peritonitis. Patients who developed PLT after their first LT had a significantly greater risk of graft loss or mortality compared to unaffected patients. Parameters significantly associated with these adverse outcomes by multivariate analysis were recipient age at LT and bowel leak or perforation after LT. In conclusion, PLT is a serious infectious complication of LT, associated with significant intra-abdominal pathology and reduced recipient and graft survival.

Outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities in autoclave steam moisture.

BACKGROUND: Toxic anterior segment syndrome (TASS), a complication of cataract surgery, is a sterile inflammation of the anterior chamber of the eye. An outbreak of TASS was recognized at an outpatient surgical center and its affiliated hospital in December 2002. METHODS: Medical records of patients who underwent cataract surgery during the outbreak were reviewed, and surgical team members who participated in the operations were interviewed. Potential causes of TASS were identified and eliminated. Feedwater from autoclave steam generators and steam condensates were analyzed by use of spectroscopy and ion chromatography. RESULTS: During the outbreak, 8 (38%) of 21 cataract operations were complicated by TASS, compared with 2 (0.07%) of 2,713 operations performed from January 1996 through November 2002. Results of an initial investigation suggested that cataract surgical equipment may have been contaminated by suboptimal equipment reprocessing or as a result of personnel changes. The frequency of TASS decreased (1 of 44 cataract operations) after reassignment of personnel and revision of equipment reprocessing procedures. Further investigation identified the presence of impurities (eg, sulfates, copper, zinc, nickel, and silica) in autoclave steam moisture, which was attributed to improper maintenance of the autoclave steam generator in the outpatient surgical center. When impurities in autoclave steam moisture were eliminated, no cases of TASS were observed after more than 1,000 cataract operations. CONCLUSION: Suboptimal reprocessing of cataract surgical equipment may evolve over time in busy, multidisciplinary surgical centers. Clinically significant contamination of surgical equipment may result from inappropriate maintenance of steam sterilization systems. Standardization of protocols for reprocessing of cataract surgical equipment may prevent outbreaks of TASS and may be of assistance during outbreak investigations.

Spectrum of pneumonia in the current era of liver transplantation and its effect on survival.

OBJECTIVE: To examine the frequency and microbial pattern of pneumonia and its effect on survival in the current era of orthotopic liver transplantation (OLT). PATIENTS AND METHODS: At the Mayo Clinic in Jacksonville, Fla, the medical records of consecutive patients who underwent their first OLT between February 1998 and January 2001 were retrospectively reviewed through the end of the first year posttransplantation. RESULTS: Of 401 study patients, 20 developed pneumonia; estimates of incidence with corresponding 95% confidence interval (CI) at 1 and 12 months were 3% (1%-5%) and 5% (3%-7%), respectively. Pseudomonas aeruginosa was the predominant microorganism identified (in 8 of 14 patients) during the first month after transplantation. Between the second and sixth months, 2 of the 4 cases of pneumonia were due to fungal infections of Aspergillus fumigatus. Cytomegalovirus was associated with Aspergillus in 1 patient. No other viral or Pneumocystis carnil pneumonia was diagnosed. There were only 2 cases of pneumonia between 7 months and 1 year after transplantation, neither of which was fungal. Approximately 40% (95% CI, 14%-58%) of patients with pneumonia died within 1 month after diagnosis. The relative risk of mortality in the first month after onset of pneumonia was estimated to be 24 (95% CI, 10-54), which is strong evidence of increased risk of mortality with pneumonia (P<0.001). CONCLUSIONS: Pneumonia appears to occur less often after OLT than previously reported but still has a substantial negative effect on survival. In the early period after OLT, P. aeruginosa continues to be the predominant organism causing pneumonia.

Risk stratification and targeted antifungal prophylaxis for prevention of aspergillosis and other invasive mold infections after liver transplantation.

Antifungal prophylaxis has been proposed for liver transplant recipients at increased risk for invasive mold infection. Risk factors for invasive mold infection after liver transplantation were selected to divide recipients into 3 groups: (1) high risk-transplantation on hemodialysis or delay of hospital discharge beyond day 7 after transplantation because of allograft or renal insufficiency; (2) intermediate risk-retransplantation or transplantation for fulminant hepatic failure; (3) low risk-absence of conditions in groups 1 and 2. During an intervention period (February 1999-April 2001), prophylactic administration of a lipid complex of amphotericin (Abelcet) at 5 mg/kg intravenously every 24 to 48 hours was recommended for high-risk recipients. The frequency of mold infection was compared to that of a preintervention period (February 1998-January 1999) when antifungal prophylaxis was not provided. During the intervention period, invasive mold infection developed in 2 (6%) of 35 high-risk recipients, 0 of 28 intermediate-risk recipients, and 1 (0.5%) of 187 low-risk recipients. Overall, of 58 liver transplant recipients, 3 (5%) developed an invasive mold infection during the preintervention period, compared with 3 (1%) of 250 during the intervention period (P = 0.08). The only death from invasive mold infection occurred during the preintervention period. Rates of pulse corticosteroid treatment of rejection and cytomegalovirus infection were lower during the intervention period. In conclusion, readily identifiable patient characteristics can be used to stratify liver transplant recipients for risk of invasive mold infection. Antifungal prophylaxis given to high-risk recipients may provide cost-effective prevention of these infections.